Web audio at CurrentPsychiatry.com Dr. O’Connell: What you need to know about treating athletes

Playing through the pain: Psychiatric risks among athletes

Injuries, other factors increase athletes’ vulnerability to psychopathology

uck it up. Tough it out. There is no “I” in team. These are a few of the messages athletes receive from coaches, Steammates, and fans. There are norms, values, and expectations in every culture, including sports, that af- fect behavior and emotional expression. When taking a patient’s history, clinicians may ask about participation in sports because it provides health and lifestyle informa- tion. However, many clinicians fail to consider the extent to which sport participation can influence a person’s explana- tory style, experience of injury, and attitude toward medi- cations. Whether your patient is an elite athlete or someone who participates in sports solely for exercise, the extent to which he or she identifies as an athlete is worth exploring. © OCEAN/CORBIS Research on athletes has focused on physical aspects of Samantha O’Connell, PhD injury, but this may be just a small component of an ath- Clinical Psychologist lete’s devastation after serious injury. In this article, we dis- Performance Enhancement Consultant Boston, MA cuss athletes’: • psychiatric risks after injury Theo C. Manschreck, MD, MPH Professor of Psychiatry • expression of pain Harvard Medical School • risks of having an identity driven solely by sports Boston, MA • distress tolerance. We also provide tips for making a differential diagno- sis and providing treatment. This information is based on our experience treating athletes, supplemented by relevant literature.

Psychiatric risks after injury Research has explored eating disorders and substance use among athletes, but clinicians generally are less aware of Current Psychiatry 16 July 2012 the prevalence of mood and anxiety disorders in this popu- lation. Although participating in sports of sport with their own being may under- can protect against emotional distress, ath- report physical and psychiatric symptoms. letes who sustain an injury are at risk for In a survey of National Collegiate Athletic major depressive disorder, posttraumatic Association Division I athletes, Nixon9 stress disorder (PTSD), or an adjustment found that 70% of respondents reported disorder.1 Only about 10% of injured ath- having been injured at least once, and letes have severe, long-term psychological more than one-half felt pressure to play consequences,2 but the prevalence of an- while injured. Feeling pressure to perform ger and depression after an injury is well with injury was affected by “starter” sta- documented.3,4 Researchers have found tus, and whites and men scored highest on that injured athletes experience clinically pressure scales, although women showed significant depression 6 times as often a roughly equal probability of playing as non-injured athletes.5 Injured athletes through injury. Students who received also exhibit significantly greater anxiety an athletic scholarship experienced more and lower self-esteem than non-injured injuries that required surgery. There was controls immediately after injury and at no difference in pain expression between 2-month follow-up; those with more se- players of contact and non-contact sports. Clinical Point vere injuries are more likely to become Finally, athletes may be less likely to seek Understanding the depressed.6 Non-injured athletes seem to pharmacologic treatments because of cul- experience depression at the same rate as tural messages that emphasize ideas such meaning of an injury the general population.7 as “the body is a temple.” to the athlete is crucial to achieving recovery Injury and expression of pain Loss of identity Psychiatric illnesses often are underreport- An athlete’s injury should be analyzed for ed and undertreated in athletes.8 This may meaning; what may seem insignificant to be because athletes feel that admitting they one person may be quite different for an- have a psychiatric illness or symptoms other. When injury makes athletic activity could threaten their status with their team. impossible, an athlete may suffer more dis- One professional figure skater we treated tress than someone who does not exercise failed to seek recommended treatment for regularly. Understanding the significance a psychiatric disorder because she feared of the experience for an athlete is crucial she would be asked to leave her skating to achieving recovery.10 For example, to a company. Her symptoms dangerously es- non-athlete a fractured wrist may be an an- calated before she was hospitalized. noyance, but it may be disastrous to a col- Based on our clinical experience, legiate pitcher who is forced to be inactive many athletes feel acute pressure to play when scouts for Major League Baseball through psychological and physical pain. teams search for prospects. Some athletes continue to play with an in- To an athlete, injury can mean loss of jury to hold on to a paycheck or scholar- identity. Whereas most people become ship. Some continue to play even though competent in many aspects of life, and they no longer enjoy the sport to prevent develop support systems across multiple letting down parents or coaches; others contexts, an athlete—particularly an ex- know no other way but to “tough it out.” traordinarily talented one—may have fo- Supporters such as coaches, parents, or cused only on his or her sport. Although teammates may encourage athletes to play athletics can help young people develop Discuss this article at with injury, and sometimes provide medi- confidence, participation also can be a trap. www.facebook.com/ CurrentPsychiatry cation to do so. Individuals with strong athletic identities Mostly, however, the pressure to contin- are less likely to explore other career, edu- ue to play despite injury comes from ath- cational, and lifestyle options.11 In the con- letes themselves. The culture of sport may text of team sports, an athlete may feel less lead athletes to minimize pain, fear, and emotionally supported if an injury results Current Psychiatry self doubt.9 Athletes who fuse the culture in the loss of his or her central role with Vol. 11, No. 7 17 Box Athletes and suicide: Who is at risk?

uicides by several high-profile athletes have For some athletes, career-ending injuries Scalled attention to the severity of psychiatric lead to suicidal behaviors. A study of 5 risks among athletes. In June 2002, 20-year-old athletes who attempted suicide after Nathan Eisert died of a self-inflicted gunshot sustaining an injury found 5 common wound 5 weeks after being released from the characteristics: Psychiatric risks Western Kentucky University basketball team • all were successful in their sport before among athletes for academic reasons; the year before, he had getting injured suffered a serious ankle injury.13 Former National • all sustained an injury severe enough to Football League (NFL) player Kenny McKinley warrant surgery committed suicide in September 2010, after a • all endured a lengthy rehabilitation knee injury sidelined him.14 In May 2012, former • all were not as successful at their sport NFL star Junior Seau, who had retired in 2011, when they returned to play fatally shot himself.15 • all were replaced by a teammate.16

Clinical Point the team. Helping athletes form an identity dition, without the support of the athletic Overtraining that is not based solely on sports is ideal “family” (eg, teammates, coaches, staff) because subsequent injuries could lead to many athletes turn to alcohol or drugs un- syndrome shares recurrent struggles with loss of identity. less they have alternate coping strategies symptoms with Athletes who achieve higher levels of suc- and social supports.18 depression but cess have higher levels of depression and can be reversed by higher suicidal ideation after injury.12 An athlete may attempt or complete suicide, Overtraining and stress reducing activity particularly those who are injured (Box).13-16 The differential diagnosis for athletes who present with psychiatric symptoms in- Student athletes. When working with cludes several mood and anxiety disorders student athletes, it is crucial to understand and other conditions (Table). When evalu- the lifestyle that promotes forming a single- ating athletes who have depressive symp- factor identity. Student athletes may be toms, it is essential to rule out overtraining required to train 2 or 3 times a day, rarely syndrome (OTS). A common phenomenon spend their school breaks in tropical loca- among athletes, OTS is characterized by tions, often miss social events, and may athletic “staleness” and chronic fatigue.19 forgo commencement ceremonies. When Although there are no official OTS diag- an injury suddenly makes these perpetual nostic criteria, characteristic symptoms sacrifices seem to be in vain, the risk of psy- include decreased physical performance chiatric illness may increase. or stamina, fatigue, insomnia, change in appetite, irritability, restlessness, excitabil- ity, anxiety, weight loss, loss of motivation, Tolerating distress and poor concentration.19 The primary dis- Athletes often use their sport as an outlet tinction between OTS and depression is for emotional expression. When an injury that OTS results from athletic endeavors removes that outlet, an athlete may devel- and can be reversed by reducing activity. op anxiety and disappointment. Left alone Experiencing an injury—or even a near- to manage these emotions, an athlete may miss—can be terrifying to a person who become irritable, passive, socially isolated, derives his or her identity from a fully depressed, or suicidal.17 Trying but failing functioning body and feels that a perfectly to find socially acceptable ways to express working body is essential to an acceptable these feelings may intensify depression or life. Such athletes may develop acute stress anger. Difficult life issues, such as avoided disorder or PTSD.20,21 We treated a hockey losses, relationship issues, or various inse- player who just missed being involved in curities, may come to the surface when an a serious incident on the ice. “I watched Current Psychiatry 18 July 2012 athlete’s primary coping skill is lost. In ad- my whole athletic career up to that point flash before my eyes.… I keep getting Table flashes of that,” he said. After the incident, he experienced hypervigilance, avoidance, Differential diagnosis of and anxiety—both on and off the ice—and conditions associated with was diagnosed with acute stress disor- athletic injury der. Similarly, we cared for a young run- Acute stress disorder ning back whose physical symptoms had Adjustment disorder abated after experiencing a concussion. Anxiety disorder NOS He developed an irrational fear that he Depressive disorder NOS would become injured again. Neither ath- Major depressive disorder lete had a history of psychiatric illness or Overtraining syndrome serious injury, and both were paralyzed by the idea of returning to play. One of these Postconcussion syndrome athletes successfully engaged in exposure Posttraumatic stress disorder therapy, and the other experienced se- NOS: Not otherwise specified vere avoidance, hopelessness, depression, nightmares, and flashbacks before seeking Clinical Point treatment. requires understanding the meaning of ath- Helping an injured letics in your patient’s life and the extent to which he or she has “back-up” stress reliev- athlete find other Substance use: Common and risky ers and support systems, and assessing for outlets to replace Anecdotal and clinical evidence suggests cognitive dysfunction that may contribute athletics may reduce that athletes in different sports engage to mood or anxiety symptoms. During eval- emotional distress in different substance abuse patterns. uation, take a careful history to distinguish Studies show that college athletes use al- major depression or adjustment disorders cohol at higher rates than non-athletes.22,23 from OTS, and assess for PTSD symptoms. In 2000, the American College of Sports When treating an injured athlete, help the Medicine reported that athletes’ abuse patient determine whether he or she can of recreational drugs far surpasses their find another outlet—preferably more than abuse of performance-enhancing drugs.24 one—to replace athletics. Some athletes may use prescription pain For an athlete who has depressive medications recreationally or to self- symptoms, we recommend determining medicate emotional pain as a result of whether the patient’s symptoms remit af- injury. Athletes may not understand the ter a brief period of rest before initiating risks of recreational use of prescription pharmacotherapy. For patients who exhib- medications or illicit substances—such as it minimal neurovegetative features, we cocaine’s deleterious cardiovascular ef- recommend psychotherapy as a first-line fects—and may hesitate to discuss their treatment. Many athletes are reluctant to self-medicating with physicians. take medication and would be more likely Some athletes abuse performance- to follow through with cognitive-behav- enhan­cing drugs, such as anabolic steroids, ioral and biofeedback interventions. androstenedione, stimulants, diuretics, If a patient requires pharmacotherapy, and creatine.25 Side effects of these sub- ask about his or her feelings toward medi- stances include liver disease, brain hemor- cations that may impact adherence. For ex- rhage, weight loss, and depression.25 ample, is a gymnast worried about weight gain? Is a sprinter concerned with leth- Our recommendations argy? When prescribing, be aware of the Working with athletes—particularly in- prevalence of drug and alcohol problems jured athletes who have internalized sports among athletes, understand how habits culture—requires informed clinical effort, and temptations differ among sports cul- whether your patient is a student athlete, tures, and provide patients with psycho- elite athlete, leisure athlete, or former ath- education about substance abuse when Current Psychiatry lete. Successful diagnosis and treatment appropriate. Vol. 11, No. 7 19 continued stage theories to challenge the development of the injured Related Resources collegiate athlete. J Athl Train. 2003;38(1):75-82. 11. Brown C, Hartley DL. Athletic identity and career • International Society for Sports Psychiatry. http:// maturation of male college student athletes. International sportspsychiatry.org. Journal of Sport Psychology. 1998;29(1):17-26. • Sabo D, Miller KE, Melnick MJ, et al. High school athletic par- 12. Baum AL. Suicide in athletes: a review and commentary. ticipation and adolescent suicide: a nationwide U.S. study. Clin Sports Med. 2005;24(4):853-859, ix. Int Rev Sociol Sport. 2005;40(1):5-23. http://www.ncbi.nlm. 13. Ho J. Suicide on campus. CBS News. http://www.cbsnews. nih.gov/pmc/articles/PMC2563797. Accessed June 7, 2012. com/2100-500195_162-654130.html. Published February 11, 2009. Accessed June 7, 2012. Disclosure 14. Bunch J, Jones LH. Broncos WR Kenny McKinley found Psychiatric risks dead in apparent suicide. Denver Post. http://www. The authors report no financial relationship with any company among athletes denverpost.com/sports/ci_16127852. Published September whose products are mentioned in this article or with manufactur- 20, 2010. Accessed June 7, 2012. ers of competing products. 15. Saraceno J. Junior Seau’s death came with ‘zero warning.’ USA Today. http://www.usatoday.com/sports/football/ nfl/story/2012-05-02/junior-seau-dead-gunshot/ 54712488/1. Published May 3, 2012. 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Bottom Line Treating athletes who develop psychiatric illness requires understanding the importance of sports in the patient’s life. Athletes may form an identity based on participation in sports, and disruptions to this lifestyle caused by injury or other factors can result in depression, anxiety, stress disorders, or suicide. For athletes who have depressive symptoms, psychotherapy may be preferred to pharmacotherapy Current Psychiatry 20 July 2012 as a first-line treatment.